Will patient lose Tricare after enrolling in long term care plan?
February 15th, 2012 | TriCare Help | Posted by Military Times
I work for a Medicare Advantage plan, a special needs plan for people who live long term in a nursing home and have Medicare Parts A and B. We have someone who wants to enroll a parent who has Tricare. I know we work with Tricare, but wanted to check with you and make sure this person is not at risk for losing any benefits of any kind. Do you know if there is a scenario where it is possible that a Tricare member can be at risk when joining another plan?
I know of no way a Tricare beneficiary can lose Tricare eligibility by joining another plan.
One thing that must always be kept in mind, however, is that, by federal law, Tricare is always last payer to all other coverage. That is, claims must be filed with all other coverage first, and each plan must pay its maximum benefits before a Tricare claim may be filed.
For more information about Tricare and other coverage plans, please go to www.tricare.mil/claims or contact the Tricare Regional Managed Care Contractor at that link.
How does doctor’s office file a Tricare claim?
December 23rd, 2011 | TriCare Help | Posted by Military Times
If Tricare is secondary to a commercial insurance, will Tricare pay the primary insurance’s copayment? Our medical practice treated the child of a parent who gave Health Alliance insurance as a primary carrier and Tricare “Active Duty Family Member” as the secondary insurance. The parent refused to pay the primary insurance co-pay and stated Tricare will pay the copay when Tricare is billed.
By federal law, Tricare is always last payer to all other health insurance. In most cases, Tricare will pay whatever the patient’s other coverage did not pay for covered services, up to, but not more than, the amount of the Tricare allowance. That will usually include payment of the patient’s share of the other plans benefits — his copayment and, when applicable, his deductible — withheld by the other plan.
Here’s how to file the Tricare claim and to be paid directly by Tricare:
1. Complete and sign a proper claim form, accepting assignment of benefits.
2. Attach a copy of exactly the same bills as were submitted to the other plan.
3. Attach a copy of the other plan’s EOB.
4. Send the claim to the proper Tricare claims processing contractor.
5. The claim must be filed within one year from the date of service.
For mailing instructions or help with the claim, visit Tricare’s website. The site also maintains a section specifically designed for provider information. To become a primary provider for Tricare beneficiaries, you must register with Tricare and become an authorized provider. That requirement is similar to that seen with commercial policies.
Do I have to cancel employer’s policy to use Tricare for Life?
December 9th, 2011 | TriCare Help | Posted by Military Times
I will turn 65 later this year and become eligible for Medicare and Tricare for Life. I have another health insurance policy through my employer. I’ve heard that I have to cancel the other policy to use Tricare for Life, but my wife and children still need that coverage. I asked and was told that I can’t cancel just my own coverage and leave my family insured under my employer’s plan. What can I do?
You were misinformed. You do not need to cancel your other health insurance policy to qualify for Tricare for Life. The legal requirement regarding other health insurance is that Tricare must always be last payer to all other coverage, except welfare-related plans such as Medicaid.
When Tricare beneficiaries become entitled to Medicare and are enrolled in Part B, they are covered under Tricare for Life. If they have no other health insurance, Tricare Standard acts as a free Medicare supplement and last payer to Medicare.
After it processes a claim and makes whatever payment is due, Medicare automatically transfers the claim to Tricare electronically. In the vast majority of claims, Tricare pays whatever Medicare did not pay for Tricare-covered services — usually the beneficiary’s Medicare deductible and co-payment.
Your situation will be different because of your other health insurance. As you read the following, keep in mind that Tricare must always be last payer to all your other coverage, regardless of which plan is first or second payer.
Let me summarize the situation regarding your family:
Tricare for Life rules do not require you to cancel or alter your employer’s health insurance policy. You and your family may continue coverage under your employer’s plan. Regardless of decisions you make about your Medicare coverage, your family’s Tricare coverage as second payer to your employer’s plan will not be affected.
Now, the following pertains to you only, not your family:
When you become entitled to Medicare, you will be told that Medicare does not require you to enroll in Part B as long as you continue to work for the employer that provides the other health insurance. Also, for as long as you continue to work for that employer, your employer’s plan will be your primary coverage. Medicare will be second payer.
Although Medicare’s rules allow you to postpone Part B enrollment for as long as you continue to work, Tricare’s rules do not allow that.
According to law, retirees or their family members who become entitled to Medicare must enroll in Part B of Medicare in order to retain Tricare eligibility.
If you feel that Medicare Part A plus your employer’s plan is enough health insurance for you (yourself only) while you continue to work, you might want to postpone Part B enrollment during that period. That will allow you to avoid paying the monthly premium for Part B. But you will be ineligible for Tricare for Life until you enroll in Part B.
That’s a decision only you can make. Before you do, I suggest you contact Medicare for details about the kinds of health care services Part A covers.
You’ll want to enroll in Part B, however, as soon as you stop working. Your Tricare eligibility will be restored as soon as you do that and your Defense Enrollment Eligibility Reporting System (DEERS) record has been updated.
For as long as you continue to work, you must file claims with your employer’s plan first. Medicare Part A will be second payer to that plan. You will no longer have Tricare as a last-payer backup because you are not enrolled in Medicare Part B.
When you are no longer working, you will file claims with Medicare first. Your employer’s plan will be second payer to Medicare. If you have enrolled in Part B, Tricare will be last payer to your other coverage.
Depending on the extent of the other plan’s coverage, it will very likely pay what Medicare does not pay in much the same way that Tricare would. After Medicare and the other plan have both completed processing and you have the explanations of benefits from both, you may file a claim with Tricare for any amounts they left unpaid.
As I said earlier, regardless of decisions you make, your family members will continue to have your employer’s plan as their primary coverage and Tricare as second payer on their claims. Their Tricare coverage will not be affected by your Medicare entitlement or the decision you make about Part B enrollment.
Do we have to use other health insurance if it’s available?
November 22nd, 2011 | TriCare Help | Posted by Military Times
My husband has Tricare Prime. He is considering a full-time job with full benefits. If health insurance is an optional benefit, does Tricare require that he take it?
No, Tricare does not require or forbid its beneficiaries from enrolling in other health insurance. It is completely up to the beneficiary. However, if he is enrolled in other health insurance, federal law requires that he use (file claims with) that plan first.
After the other health insurance has processed the claim, paid its maximum, and issued an Explanation of Benefits, the beneficiary or the provider may file a Tricare claim for all amounts the other insurance may have left unpaid. Usually, that will be the patient’s copayment and, when applicable, the deductible. That is commonly called the “patient’s share” of the bills.
The Tricare claim must consist of:
- A properly completed Tricare Claim Form DD2642;
- A copy of exactly the same bill(s) that was/were sent to the other health insurance;
- A copy of the other insurance’s EOB reporting its actions on each of the charges on the provider’s bill.
Send the package to the proper Tricare claims processing contractor for your place of residence.
When your other health insurance is under a different name
October 31st, 2011 | TriCare Help | Posted by Military Times
I work in the airline industry and can enroll in my employer’s insurance. I also have Tricare Standard as my secondary insurance — my husband is deceased. However, the Tricare coverage is under my married name, and everything with my employer is under my maiden name. Will this cause a problem when I try to file a claim with Tricare as my secondary insurance? I need to enroll in my employer’s insurance soon.
Your problem is a simple administrative issue requiring an explanatory letter. How quickly it gets resolved depends on who gets the letter and when.
Write to your Tricare claims processing office — the same place where you submit Tricare claims — and explain the situation. Make three or four extra copies. Send the letter to the claims processor now, and send another copy with the first claim you submit to Tricare as second payer.
If it doesn’t take, you will know in a few weeks after you submit your first claim to Tricare as second payer. If your claim is denied, it isn’t a disaster; you just need to file and appeal.
If Tricare simply writes asking for more information, no appeal is needed. Just reply immediately, explaining everything again, and include a copy of the letter Tricare sent you so they know what you’re talking about.
If Tricare denies the claim, then it’s time to file an appeal. The appeal must be in writing and state the specific matter in dispute: For example, “Tricare denied claim number X because I used two different names on the claims. I have attached an explanatory letter.”
Attach a copy of the explanatory letter with the appeal letter. Include also a copy of Tricare’s explanation of benefits showing the claim denial.
Send the appeal letter, the explanatory letter, and Tricare’s EOB showing the denial to the address of the Tricare office that denied the claim. It’s on the Tricare EOB. Be sure to answer all questions Tricare asks, if any. That should resolve the name problem.
Does Tricare need to know about my primary insurance?
October 7th, 2011 | TriCare Help | Posted by Military Times
Do I need to let Tricare know our primary insurance information with United Health Care, as we are using Tricare as our secondary insurance? Most doctors will be filing the claims, and I wanted to make sure Tricare was aware of our other insurance. Also, I need the address that the claims should be mailed to — we are in the North Region.
It is not necessary for you to advise Tricare of your other health insurance as long as you use it first. There will be a space on its claim form for you to put the name and address of your other plan, which is Tricare.
By federal law, Tricare is always last payer to all other sources of medical payments including other health insurance, medical plans such as a Health Maintenance Organizations, or medical payments from insurance payments or a lawsuit, such as the result of an auto accident, slip-and-fall, dog bite, and the like.
The only time Tricare pays first is if the other coverage is a bona fide, specially written Tricare supplement or a welfare-related plan such as Medicaid (not Medicare).
As you correctly assumed, you must file all claims with your commercial plan first. After it completes processing and issues an Explanation of Benefits, it will probably forward the claim to Tricare as second payer. If it does not, you will have to do it yourself. In that event, please see below.
After the other plan has completed all processing, paid its maximum, and has issued an Explanation of Benefits (or EOB – the processing report a plan issues when all its actions have been completed), the patient or provider may file a Tricare claim. As second payer, Tricare will usually pay most, or all, of what the other plan did not pay. That will usually be your co-payment, and any part of its deductible that has not been satisfied previously.
The Tricare claim must consist of:
- A properly completed Tricare Claim Form DD2642;
- A copy of exactly the same bills as were submitted to the other plan;
- A copy of the other plan’s EOB reporting its actions (payment, denial, crediting to the deductible) on each of the charges submitted to the other plan.
For official information and instructions about filing the claim with Tricare, including the filing addresses for all regions and to download claim forms, visit the Tricare website. If you need additional help, please call your Regional Tricare Service Center.
How do we decide between Tricare Prime and FEHBP?
September 8th, 2011 | TriCare Help | Posted by Military Times
My husband is retiring from the military and now is eligible for the Federal Employee Health Benefits Program through his new job. He has minimal health issues, but I have a history of cancer and other problems. Should we enroll in FEHBP or use Tricare Prime? The premiums alone for FEHBP equal or exceed Tricare’s yearly $3,000 catastrophic cap. If we had both, could the FEHBP deductibles, copayments and premiums count toward Tricare’s catastrophic cap?
I cannot tell you exactly what you “ought” to do regarding your health insurance coverage; nobody can make that decision except you and your husband. But I can give you as much information as possible about Tricare to help you make that decision.
Tricare Prime functions as a Health Maintenance Organization (HMO). Tricare Prime providers (called network providers) are under contract with Tricare to provide the services mandated by law and regulation to beneficiaries enrolled in Prime.
They have privately negotiated with Tricare the fees they will charge for each of their services, but that’s between Tricare and the provider only. All the patient must be concerned about is the flat rate of $12 he or she must pay per office visit, or the flat rate of $11 per day for hospital stays.
Prime is not available everywhere. It is usually found within a 40- 50-mile radius of a military treatment facility. Tricare beneficiaries enrolled in Prime have priority access, right after active-duty family members, to free care at the MTF.
As with commercial HMOs, you must seek all care, except bona fide medical emergency care, from providers in your local network.
If you take a trip, clear it first with Tricare Prime, because on the road, “routine” care will not be covered inexpensively. There are considerable penalties ($300 deductible, 50 percent cost share) on claims for unauthorized care by non-network providers.
People have exactly the same problems with commercial HMOs under the FEHBP. Personally, I like HMO care except for the limited choice of providers, and the inconvenience if one travels. They are most like military sick call. The big ones have everything — labs, etc. under one roof, plus centralized record-keeping, central appointments, and the like. Big civilian HMOs may even own their own hospital. And their low cost is a big factor.
Like many things in life, it’s a trade-off. Study assiduously; know before you buy. You can download a free Tricare Prime handbook here.
FEHBP deductibles and cost shares do not count for your Tricare catastrophic cap, however. Only Tricare’s deductibles and cost shares count.
How does having other insurance affect my Tricare coverage?
July 25th, 2011 | TriCare Help | Posted by Military Times
I am a military spouse, and I work as a nurse, so I have Tricare as well as my employer’s insurance. My employer and the Tricare Outpatient Clinic I visit told me that Tricare would be my secondary insurance, but neither explained what that means. I continued to see my Tricare provider and they referred me to outside doctors when their own staffing was low at the military treatment facility. Triwest is now asking all providers they had previously authorized to pay them back, and sending me notices that I owe for services they authorized with these providers. They claim they did not know I had another insurance when I had previously filled out papers at the Tricare clinic when I started coverage under my employer’s plan. How does having another insurance affects my benefits through Triwest?
When a Tricare beneficiary has other health insurance, federal law requires that Tricare must always be the last payer. That means all claims for civilian medical care must be filed first with the OHI. When the OHI has paid its maximum and has issued the beneficiary an Explanation of Benefits (the report you get from an insurer showing all of its actions in paying your claim), you may file a Tricare claim.
The Tricare claim must consist of (1) a properly completed Tricare Claim Form DD2642; (2) copies of exactly the same itemized medical bills as were sent to the OHI; and, (3) a copy of the OHI’s EOB showing the way it processed (paid or denied) each of the charges on the medical bills. You must send the completed package to the Tricare claims processor for your state or ZIP code.
(You can download official claim forms and look up the filing address here.)
As last payer, Tricare will pay all, or most, of whatever the OHI did not pay for the medical services on the bills.
You didn’t mention if you have Tricare Standard or Tricare Prime. Tricare Standard is free; Tricare Prime costs $230 per year for one person, or a maximum of $460 for a family of two or more people.
Your mention of using a military treatment facility leads me to think you have Tricare Prime. Unlike Tricare Standard, Tricare Prime functions like a Health Maintenance Organization (HMO). You may use only the health care providers that are enrolled in Tricare Prime’s Provider Network unless you are referred to other providers by Tricare Prime. According to your letter, that was the case with your medical care.
As you report, Tricare is requesting that you refund its payments made in error. According to the information in your letter, Tricare paid in error because you failed to report that you had OHI, and did not file first with the OHI as required by law. No, the cops are not going to come knocking on your door.
But, you do have some problems with having to return payments made in error by Tricare. Pursuant to that, you need more help than Tricare Help can give you.
Please write to the Tricare Headquarters about this matter. The address is Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043.
With your letter, please explain the problem in detail, include your full name as it appears on your military ID card, your husband’s name and his Social Security number, and a telephone number where you can be reached during the day. Include copies of any correspondence, bills, EOBs, and the like, that pertain to the problem. The more information you can provide, the more efficiently Tricare can serve you.
Tips for starting to use Tricare and shopping for supplements
April 1st, 2011 | TriCare Help | Posted by Military Times
I am retired from the Army but have never used Tricare. I use health coverage provided by my employer. I will retire in 18 months, however, and my health coverage will end. I will be 58 when I retire. What do I do, and how far in advance should I start converting to Tricare? Do you recommend a supplement?
About 30 days before your last day of coverage by your other health insurance, write to the Tricare Headquarters to advise that you are going to cancel that insurance. The address is Tricare Management Actvity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. Include your full name, Social Security number, and the full names of any family members who are covered by that plan.
Include with your letter an official statement written by your other plan on its official stationery which states your last date of coverage by that plan. You will need to advise any health care providers as well so they will file appropriately with Tricare.
To use Tricare, your DEERS record must be kept up-to-date and report that you are eligible for Tricare. Please call the DEERS Support Office, toll-free, at 1-800-538-9552 to ensure that your DEERS record is correct and up-to-date so you will have no lapse in coverage. It is most likely that your Tricare coverage is in effect now, provided you have kept your DEERS record and military ID card up-to-date.
People with no health insurance other than Tricare are well-advised to purchase a good Tricare supplement. Most of the military associations sell a Tricare supplement. They vary, however, in their price, what they cover, and their rules for doing it.
I suggest that you request a copy of the policy from several plans and read the fine print carefully. Make sure you buy the plan that best meets your needs and that it is a bona fide Tricare supplement. A bona fide Tricare supplement describes itself as a Tricare supplement in writing in the plan itself. In the policy, look at such things as its policy concerning coverage for pre-existing conditions; how long you must be hospitalized before the plan begins to pay; and whether it has limits on the amount it will pay during a coverage period. Tricare has a helpful list of issues to consider. Do not allow price to be the most important factor in your decision.
How do I keep coverage for younger husband when I get TFL?
March 25th, 2011 | TriCare Help | Posted by Military Times
Q. I’m a retired reservist and retired federal employee with employees’ health insurance. I have a civilian husband who is three years younger, but no children. I’ll be 65 in August and get Medicare and Tricare for Life. What can I do at that time to ensure I still have coverage for my husband?
When you transition to Tricare for Life on Aug. 1, your husband’s federal employee plan and Tricare coverage will continue unchanged until he gets Medicare at age 65 — assuming you keep your own coverage under the federal employees plan. Family members can’t be covered unless the former employee also is covered. Confirm this with the Office of Personnel Management.
For your own transition, you should apply for Medicare Part A and Part B at least 90 days before Aug. 1. If you enroll properly, your coverage will be effective on that date. If your Defense Enrollment Eligibility Reporting Service record reflects your Part B enrollment, you will retain your Tricare eligibility and become eligible for TFL.
TFL consists of full coverage by Medicare Parts A and B plus Tricare Standard. Because you must retain your federal employee plan coverage for your husband’s benefit, however, that plan — not Tricare — will be second payer on your Medicare claims. Tricare Standard will be last payer, and you must file those claims yourself.
Call the DEERS support office at 800-538-9552 to check the accuracy of your and your husband’s DEERS records.